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Objective: Penetrating aortic ulcers can be a concerning finding on imaging. They are believed to be the predecessors for intramural hematomas, dissections and aneurysm degeneration. It is hypothesized that penetrating ulcers of the abdominal aorta (PUAA) and iliac arteries (PUIA), like their thoracic counterparts, signal impending vascular catastrophe.
Methods: With the institution of electronic medical records at our health system in 2010, a search for the words “penetrating ulcer” in radiology reports became possible. Fifty-three patients were identified as having a penetrating ulcer of the abdominal aorta (PUAA) on CTA over a 10 month period from October 2010 through August 2011. Thirty-four patients were identified as having a penetrating ulcer of the iliac vessels (PUIA). The patients’ clinical course was followed through August 2014. No specific intervention for the ulcers was performed; however, if the patient had additional aortic pathology necessitating intervention, it was performed. Retrospective and prospective review of imaging was performed when possible. Student’s t and chi square tests were performed for statistical analysis.
Results: The table below compares the two populations studied, PUAA and PUIA.

	PUAA, n=53	PUIA, n=34	p
Age (years)	76.7 ± 10.2	74.5 ± 10.0	0.315
Males	35 (66%)	28 (82%)	0.097
Length of Follow-up (months)	35.7 ± 29.9	34.7 ± 20.6	0.613
Patients w/Serial Imaging	30 (57%)	19 (60%)	0.940
Length of Time for Serial Imaging (months)	20.6 ± 30.5	29.6 ± 19.7	0.626
Concurrent Aortic Dissection or Aneurysm	23 (46%)	19 (56%)	0.255
Change in Ulcer Appearance or Aortic Diameter	13 of 30 (43%)	1 of 19 (5%)	0.004
If Change, Worsening	8 of 30 (27%)	1 of 19 (5%)	0.059
Deceased During Follow-up	19 (36%)	7 (21%)	0.129
Cause of Death Related to Aortic Pathology	5 of 19 (26%)	1 of 7 (14%)	0.518

Eight patients had both PUAA and PUIA. Of the five PUAA deaths related to aortic pathology, one died from complications related to type B dissection, three died from complications related to lower extremity thromboembolism, and one died from multisystem organ failure after attempted surgical repair of his iliac artery aneurysm. The one PUIA death related to aortic pathology died from complications related to lower extremity thromboembolism.
Conclusions: The patients identified with penetrating ulcers of the abdominal aorta and iliac artery were generally elderly with multiple comorbidities. A large percentage of patients had concurrent, separate, aortic pathology, most frequently aortic aneurysms which were treated if size indicated. Small changes in the appearance of the PUAA were frequent, but did not equate with abdominal aortic catastrophe. Thromboembolic events occurred not infrequently in these patients. The mortality for these populations was high, but the change noted in the ulcers’ appearance during follow up did not suggest ulcer treatment would improve survival.